무통분만

이해진,전진영 대한의사협회 2010 대한의사협회지 Vol.53 No.1

We discuss recent advances in the administration of labor analgesia aimed at a more effective birthing experience for parturient women. Patient-controlled epidural analgesia (PCEA) is the most effective method of labor pain relief in medical practice. It also provides more consistent and predictable labor analgesia. When a parturient women has a contraindication to epidural analgesia, systemic analgesia techniques are provided as a guide to effective analgesia. PCEA of “low-dose” or “light mixtures” of local anesthetics and lipophilic opioids has allowed anesthesiologists to provide reasonable pain relief for most parturient women while decreasing the total dose of local anesthetics and opioids, thus minimizing the side effects of each agent. Fentanyl analgesia utilizing patient -controlled intravenous analgesia (PCIA), may provide effective self-titrated pain relief, although they are not as effective as the epidural method. Recently, remifentanil was suggested as the opioid of choice for labor analgesia. Potential advantages of remifentanil include better titration of analgesia and neonatal outcome. However,all systemic opioids rapidly cross the placenta. These drugs may cause neonatal respiratory and neurobehavioral depression. In order to reduce the incidence of breakthrough pain, more research on computer-integrated patient-controlled analgesia technology may be necessary. The study of a new local anesthetic drug that has less motor blockade and cardiotoxicity than ropivacaine is desirable, while PCEA is the most effective form of labor analgesia currently available. If epidural analgesia is contraindicated, PCI remifentanil bolus alone may be a suitable systemic analgesia for labor pain.

무통분만을 위한 경막외 마취가 제왕절개술에 미치는 영향에 관한 연구

김희범(Hee Beom Kim) 대한산부인과학회 1999 Obstetrics & Gynecology Science Vol.42 No.12

목적: 무통분만을 위해 시행한 경막외 마취가 제왕절개술의 빈도에 미치는 영향을 관찰해 보고자 하였다. 연구 방법: 1996년 1월 1일부터 1996년 12월 31일까지 분만 진통이 있어 질식분만을 위해 본원 산부인과에 입원한 산모 3051명을 대상으로 무통분만을 시행한 군 375명과 무통분만을 하지 않은 군 2676명을 대조군으로 하여 제왕절개술에 미치는 영향에 대하여 의무기록 검토를 통해 후향적으로 조사하였다. 결과: 1. 제왕절개술의 빈도는 경막외 마취를 시행한 군과 대조군 사이에 유의한 차이를 보이지 않았으나 초산모에서 기계적 분만의 빈도는 경막외 마취를 시행한 집단에서 유의하게 증가하였다(대조군:0.08%, 경막외 마취군: 6.61%). 2. 제왕절개술의 적응증중 순수하게 진행장애로 인해 제왕절개술을 시행한 빈도가 초산모에서 경막외 마취군이 대조군에 비해 유의한 증가를 보였다(63.71%: 대조군, 84.78%: 경막외 마취군). 3. 태아곤란증으로 인한 제왕절개술의 빈도는 두 집단 사이에 유의한 차이를 보이지 않았다. 4. 분만한 신생아의 Apgar 점수도 두 집단 사이에 유의한 차이를 보이지 않았다. 5. 경막외 마취 시행후 진통의 완화 정도는 초산모에서 진통을 전혀 느끼지 못했던 경우가 22.91%, 약간의 진통을 느꼈으나 산모가 주관적으로 큰 불편을 느끼지 못했던 경우가 66.96% 였고, 경산모에서는 전혀 느끼지 못했던 경우가 30.41%, 약간의 진통을 느꼈으나 산모가 주관적으로 큰 불편을 느끼지 못했던 경우가 61.48% 였다. 6. 경막외 마취를 한 집단에서 합병증으로는 요통을 호소한 경우가 30예(8.0%)로 가장 많았으며 배뇨 곤란, 떨림, 두통, 저혈압과 오심, 구토, 경막 천자 등이었다. 결론: 무통분만을 위한 경막외 마취를 시행한 초산모에서 기계적 분만 및 순수한 진행장애로 인한 제왕절개술의 빈도가 대조군에 비해 유의하게 증가하였다. 분만 통증을 당연한 것으로 받아드리던 때도 있었으나 이러한 불필요한 통증은 산과마취의 발달로 무통분만이 널리 시행되면 많이 완화되었지만 아직도 무통분만의 안전성 등에 대한 논란이 많다. 따라서 이에 대한 연구가 계속되어야 하겠지만 산과의사로서 산모가 무통분만을 원하는 경우 무통분만의 좋은 점과 기계적 분만 및 제왕절개술의 가능성, 마취 후 생길 수 있는 합병증 등에 대해 충분한 설명 및 상의를 거친 뒤에 시행하여야 할 것으로 사료된다. Objective: This study was to evaluate whether epidural analgesia of labor is associated with an increased risk of cesarean delivery. Method: The study was undertaken for the clinical evaluation on the patients with singleton infants in vertex presentations who had been admitted and delivered at Soonchunhyang Kumi Hospital from January, 1996 to December, 1996. Result: The results were as follows : 1. There was no significant difference in incidence of cesarean delivery between nulliparous women receiving epidural analgesia(20.26%) and those who did not receive epidural analgesia(19.36%). But nulliparous women who received epidural analgesia were significant increase in operative vaginal delivery than those who did not receive epidural analgesia (0.08% of the no-epidural and 6.61% of the epidural group). 2. Among the indication for cesarean section, nulliparous women who received epidural analgesia were significant increase in incidence of failure to progress only than those who did not receive epidural analgesia (63.71% of the non-epidural and 84.78% of the epidural group). 3. There was no statistic significance in incidence of fetal distress only between women receiving epidural analgesia and those who did not receive epidural analgesia. 4. There showed no significant difference in new born Apgar score between women receiving epidural analgesia and those who did not receive epidural analgesia. 5. The subjective and objective successful epidural effects were noted excellent 22.91%, good 66.96% in nulliparous women and excellent 30.41%, good 61.48% in multiparous women. 6. Concerning complications of epidural anesthesia, backache was most frequent(8.00%), voiding difficulty, shivering, nausea/vomiting, hypotension, headache, dura puncture in orders. Conclusion: Our retrospective study shows that epidural analgesia may increase substantially the risk of operative vaginal delivery and the incidence of cesarean delivery for which failure to progress only was listed as an indication in nulliparous women. Although the causal nature of this association remains open to debate, prenatal care providers should routinely discuss the risks and benefits of epidural analgesia with women during their pregnancies so that can make informed decisions about the use of pain relief during labor.

슬관절 전치환술 후 슬관절 주위주입과 병용한 지속적 정맥 진통과 지속적 경막외 진통의 비교

박정민 ( Jeong Min Park ),임영수 ( Young Su Lim ),이우석 ( Woo Suk Lee ),구자현 ( Ja Hyun Ku ),강포순 ( Po Soon Kang ),권희욱 ( Hee Uk Kwon ),조춘규 ( Choon Kyu Cho ),정성미 ( Sung Mee Jung ),양춘우 ( Chun Woo Yang ) 대한마취과학회 2009 Korean Journal of Anesthesiology Vol.56 No.1

Background: Postoperative continuous intravenous analgesia may not provide effective postoperative analgesia following total knee arthroplasty. This study was conducted to determine if combined continuous intravenous analgesia and peri-articular infiltration provided a better quality of analgesia following total knee arthroplasty than epidural analgesia. Methods: A prospective, double-blind study involving 50 patients who had undergone total knee arthroplasty was conducted. Patients were divided into control group and an experimental group. Patients in the control group (n=25) received peri-articular infiltration with 47 mL normal saline prior to closure of the wound and postoperative epidural analgesia for 48 hours. Patients in the experimental group (n=25) received a mixture of peri-articular infiltration of 16 mL of 0.75% ropivacaine, 6 mg morphine, 0.2 mg of epinephrine and 25 mL normal saline prior to closure of the wound and postoperative continuous intravenous analgesia for 48 hours. The analgesic efficacy was then evaluated using the verbal numeric rating scale at 1, 2, 6, 12, 24, and 48 hours postoperatively. The side effects and the dosage of rescue analgesics were then recorded. Results: The experimental group showed a significantly higher pain score than the control group 2 and, 6 hours postoperatively at rest and 2 hours postoperatively following passive knee movement (P<0.05). In addition, the rescue analgesic requirement was higher for the experimental group during the first 24 hours following surgery than for the control group (P<0.05). Conclusions: We found that combined continuous intravenous analgesia and peri-articular infiltration of a mixture of ropivacaine and, morphine injected into the peri-articular tissue provided minimal benefits for pain control during the early postoperative period when compared to epidural analgesia after total knee arthroplasty. (Korean J Anesthesiol 2009;56:47~53)

funcDoes Adductor Canal Block Have a Synergistic Effect with Local Infiltration Analgesia for Enhancing Ambulation and Improving Analgesia after Total Knee Arthroplasty?

( Wirinaree Kampitak ),( Aree Tanavalee ),( Srihatach Ngarmukos ),( Chavarin Amarase ),( Rawiwan Apihansakorn ),( Pannika Vorapalux ) 대한슬관절학회 2018 대한슬관절학회지 Vol.30 No.2

Purpose: We compared a single-injection adductor canal block (ACB) with or without local infiltration analgesia (LIA) for accelerating functional recovery and reducing postoperative pain after total knee arthroplasty (TKA). Materials and Methods: Sixty-two patients undergoing TKA with simple spinal analgesia and ACB were randomized to receive either LIA (group A+L) or placebo LIA (group A). Postoperative visual analog scale (VAS) score for pain, Timed Up and Go (TUG) test and quadriceps strength, total dosage of rescue analgesia, time to first rescue analgesia, and adverse events were serially evaluated from postoperative day 1 to 3 months. Results: There were no differences between both groups in pre- and postoperative VAS, TUG test, quadriceps strength 2 days, 3 days, 2 weeks, 6 weeks, and 3 months postoperatively. There were no differences in Knee Society clinical and function scores at 6 months and 1 year. However, group A+L had a significantly longer time for postoperative rescue analgesia (491 minutes vs. 143 minutes, p=0.04) with less patients requiring rescue analgesia during 6 hours after surgery (16.7% vs. 43.3%, p=0.024). Both groups had similarly high rates of patient satisfaction with low adverse event rates. Conclusions: Combined ACB and LIA in TKA enhanced early ambulation with reduced and delayed rescue analgesia.

응급실에 내원한 통증 환자에서 신속한 진통제 투여가 적절한 통증 완화에 미치는 영향

이승재,김수현,오상훈,김한준,박규남 대한응급의학회 2015 대한응급의학회지 Vol.26 No.1

Purpose: Patients presenting to an emergency department (ED) with pain related complaint continue to experience significant delay to analgesia. This study was conducted in order to evaluate the associations of adequate pain relief with analgesia and time to analgesia with ED length of stay. Methods: This study was a retrospective analysis of real time data collected from the ED. We included all consecutive patients age 18 years and above with acute painful conditions during May 2013 to June 2013. We evaluated numerical rating scale (NRS) in patients with pain on admission to the ED and re-evaluated NRS at 30 minutes after analgesia administration. Adequate pain relief was defined as reduction of 50% or more of the initial pain score. Results: A total of 560 patients met our inclusion criteria. Mean age was 44.7 years old and 52.7% were men; 13.6 % of the patients were admitted with trauma. Among them, there were significant differences in terms of the proportion of male sex and NRS between those with time to analgesia within 30 minutes and beyond. In multivariate logistic analysis, trauma, higher initial NRS and time to analgesia within 30 minutes showed association with adequate pain relief (OR=2.77, 1.14 and 1.84 respectively). Conclusion: In our study, male and patients who had higher initial NRS showed association with rapid analgesia administration. In addition, trauma, higher initial NRS, single use of analgesia, chest pain and time to analgesia within 30 minutes showed association with adequate pain relief in the emergency department.

수술 후 통증조절을 위한 지속적 경막외제통 및 정맥내 자가조절법 2,510예에 대한 임상분석

배상철,곽수달,강규식 순천향의학연구소 1998 Journal of Soonchunhyang Medical Science Vol.4 No.2

Background: The efficacy and safety of continuous epidural analgesia(CEA) and intravenous patient-controlled analgesia(IV-PCA) for postoperative analgesia on hospital wards was studied. And then we started postoperateve pain management service using a continuous epidural analgesia and intravenous patient-controlled analgesia. Method: A retrospective study was performed to evaluate the effects of continuous epidural analgesia(CEA): 0.125% bupivacaine 100ml + morphine 5~7mg or clonidine 1800㎍ and intravenous patient-controlled analgesia(IV-PCA): normal saline 20ml + fentanyl 800~1000㎍ or nalbuphine 80~100mg, for postoperative pain relief of 2,510 surgical patients who received general-epidural or epidural-regional anesthesia. Anesthesia records, patients charts, and pain control records were received and classified according to: age, sex, department, operation site, degree of pain relief by CEA and IV-PCA, and side effects(including nausea, vomiting, pururitis, urinary retention and respiratory depression). Results: 1) The study included CEA were 1,022(40.7%) patients and IV-PCA were 1,488(59.3%) patients. 2) From the total of 2,510 patients, there were 2,253(89.8%) female patients; 2,078(82.8%) patients were from Obstetrics and Gyneco]ogy. 3) In the operation site, lower abdomen were 2,053(81.8%), lower extremity were 206(8.2%), upper abdomen 136(5.4%) were order of decreasing frequency. 4) Ninety one percent of the patients experienced mild or no pain in the postoperative course. 5) There were most common complication is the nausea and vomiting. 6) There were eight cases of respiratory depression. The course of treatment consisted of: cesation of infusion, and then administration of oxygen and intravenous naloxone. Conclusions: According to our experiences, we conclude that CEA and IV-PCA is an effective, relatevely safe and highly satisfactory method for postoperative pain management.

A comparative study on analgesic and non-analgesic outcomes of inter pleural analgesia compared to thoracic epidural analgesia in open pancreatico-duodenectomy

Lu Yao,Niroshini Rajaretnam,Natalie Smith,Lisa Massey,Somaiah Aroori Korean Association of Hepato-Biliary-Pancreatic Su 2022 Annals of hepato-biliary-pancreatic surgery Vol.26 No.3

Backgrounds/Aims: Thoracic epidural analgesia (TEA) is an established analgesic method in open Kausch-Whipple pancreaticoduodenectomy (KWPD). Although, it can cause hemodynamic instability and neurological complications. Inter pleural analgesia (IPA) is an alternative option. We aim to evaluate the effectiveness of IPA versus TEA after KWPD. Methods: We retrospectively studied the efficacy of IPA against TEA in patients, operated by a single surgeon. The primary outcome was the analgesic efficacy and secondary outcomes were analgesia-related complications, inotrope use, and duration. Results: Forty patients (TEA, 22; IPA, 18) were included. Both groups were well matched for patient characteristics, type, and duration of surgery. TEA was associated with higher analgesia-related complications (n = 8, 36.4% vs. n = 1, 5.6%; p = 0.027). TEA complications included analgesia not working (n = 4), leakage (n = 2), refractory hemodynamic instability (n = 1), and lower limb anaesthesia (n = 1). One patient in the IPA group encountered leakage. TEA was associated with longer inotrope requirement (35 vs. 18 hours; p = 0.047). There was no significant difference in intensive care unit (ITU) admission rate (81.8% vs. 77.8%; p > 0.999), median ITU stay (3 vs. 2 days, p = 0.385), or hospital stay (11 days in both groups). Conclusions: In open KWPD, IPA is not inferior to TEA in its efficacy of pain control. IPA was associated with less analgesia-related complications and shorter inotrope requirements. However, this was a small retrospective study. Larger randomized controlled trials are needed to study the effectiveness of IPA.

Continuous peripheral nerve blocks (CPNBs) compared to thoracic epidurals or multimodal analgesia for midline laparotomy: a systematic review and meta-analysis

Bailey Jonathan G,Morgan Catherine,Christie Russell,Ke Janny,Kwofie Kwesi,Uppal Vishal 대한마취통증의학회 2021 Korean Journal of Anesthesiology Vol.74 No.5

Background: Continuous peripheral nerve blocks (CPNBs) have been investigated to control pain for abdominal surgery via midline laparotomy while avoiding the adverse events of opioid or epidural analgesia. The review compiles the evidence comparing CPNBs to multimodal and epidural analgesia. Methods: We conducted a systematic review using broad search terms in MEDLINE, Embase, Cochrane. Primary outcomes were pain scores and cumulative opioid consumption at 48 hours. Secondary outcomes were length of stay and postoperative nausea and vomiting (PONV). We rated the quality of the evidence using Cochrane and GRADE recommendations. The results were synthesized by meta-analysis using Revman. Results: Our final selection included 26 studies (1,646 patients). There was no statistically significant difference in pain control comparing CPNBs to either multimodal or epidural analgesia (low quality evidence). Less opioids were consumed when receiving epidural analgesia than CPNBs (mean difference [MD]: –16.13, 95% CI [–32.36, 0.10]), low quality evidence) and less when receiving CPNBs than multimodal analgesia (MD: –31.52, 95% CI [–42.81, –20.22], low quality evidence). The length of hospital stay was shorter when receiving epidural analgesia than CPNBs (MD: –0.78 days, 95% CI [–1.29, –0.27], low quality evidence) and shorter when receiving CPNBs than multimodal analgesia (MD: –1.41 days, 95% CI [–2.45, –0.36], low quality evidence). There was no statistically significant difference in PONV comparing CPNBs to multimodal (high quality evidence) or epidural analgesia (moderate quality evidence). Conclusions: CPNBs should be considered a viable alternative to epidural analgesia when contraindications to epidural placement exist for patients undergoing midline laparotomies.

Efficacy of Intrathecal Morphine Combined with Intravenous Analgesia versus Thoracic Epidural Analgesia after Gastrectomy

이재훈,구본녀,박진하,길혜금,최승호,노성훈 연세대학교의과대학 2014 Yonsei medical journal Vol.55 No.4

Purpose: Epidural analgesia has been the preferred analgesic technique after major abdominal surgery. On the other hand, the combined use of intrathecal morphine (ITM) and intravenous patient controlled analgesia (IVPCA) has been shown to be a viable alternative approach for analgesia. We hypothesized that ITM combined with IVPCA is as effective as patient controlled thoracic epidural analgesia (PCTEA)with respect to postoperative pain control after conventional open gastrectomy. Materials and Methods: Sixty-four patients undergoing conventional open gastrectomy due to gastric cancer were randomly allocated into the intrathecal morphinecombined with intravenous patient-controlled analgesia (IT) group or patient-controlled thoracic epidural analgesia (EP) group. The IT group received preoperative0.3 mg of ITM, followed by postoperative IVPCA. The EP group preoperatively underwent epidural catheterization, followed by postoperative PCTEA. Visual analogscale (VAS) scores were assessed until 48 hrs after surgery. Adverse effects relatedto analgesia, profiles associated with recovery from surgery, and postoperative complications within 30 days after surgery were also evaluated. Results: This study failed to demonstrate the non-inferiority of ITM-IVPCA (n=29) to PCTEA (n=30) with respect to VAS 24 hrs after surgery. Furthermore, the IT group consumed more fentanyl than the EP group did (1247.2±263.7 μg vs. 1048.9±71.7 μg, p<0.001). The IT group took a longer time to ambulate than the EP group (p=0.021) and had higher incidences of postoperative ileus (p=0.012) and pulmonary complications (p=0.05) compared with the EP group. Conclusion: ITM-IVPCA is not as effective as PCTEA in patients undergoing gastrectomy, with respect to pain control, ambulation,postoperative ileus and pulmonary complications.

Yin-and-yang bifurcation of opioidergic circuits for descending analgesia at the midbrain of the mouse

Kim, Jong-Hyun,Gangadharan, Gireesh,Byun, Junweon,Choi, Eui-Ju,Lee, C. Justin,Shin, Hee-Sup National Academy of Sciences 2018 PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF Vol.115 No.43

<P>In the descending analgesia pathway, opioids are known to disinhibit the projections from the periaqueductal gray (PAG) to the rostral ventromedial medulla (RVM), leading to suppression of pain signals at the spinal cord level. The locus coeruleus (LC) has been proposed to engage in the descending pathway through noradrenergic inputs to the spinal cord. Nevertheless, how the LC is integrated in the descending analgesia circuit has remained unknown. Here, we show that the opioidergic analgesia pathway is bifurcated in structure and function at the PAG. A knockout as well as a PAG-specific knockdown of phospholipase C beta 4 (PLC beta 4), a signaling molecule for G protein-coupled receptors, enhanced swim stress-induced and morphine-induced analgesia in mice. Immunostaining after simultaneous retrograde labeling from the RVM and the LC revealed two mutually exclusive neuronal populations at the PAG, each projecting either to the LC or the RVM, with PLC beta 4 expression only in the PAG-LC projecting cells that provide a direct synaptic input to LC-spinal cord (SC) projection neurons. The PAG-LC projection neurons in wild-type mice turned quiescent in response to opiates, but remained active in the PLC beta 4 mutant, suggesting a possibility that an increased adrenergic function induced by the persistent PAG-LC activity underlies the enhanced opioid analgesia in the mutant. Indeed, the enhanced analgesia in the mutant was reversed by blocking alpha 2-noradrenergic receptors. These findings indicate that opioids suppress descending analgesia through the PAG-LC pathway, while enhancing it through the PAG-RVM pathway, i.e., two distinct pathways with opposing effects on opioid analgesia. These results point to a therapeutic target in pain control.</P>